Kidane et al. BMC Medical Education            (2020) 20:7 
               https://doi.org/10.1186/s12909-019-1924-0
                RESEARCH ARTICLE                                                                                         Open Access
               Students’ perceptions towards self-directed
               learning in Ethiopian medical schools with
               new innovative curriculum: a mixed-
               method study
               Haftom Hadush Kidane1* , Herma Roebertsen2 and Cees P. M. van der Vleuten2
                 Abstract
                 Background: Self-directed learning (SDL) is an appropriate and preferred learning process to prepare students
                 for lifelong learning in their professions and make them stay up-to-date. The purpose of this study was to explore
                 preclinical students following a hybrid curriculum in Ethiopia experiences to SDL and the support of several
                 learning activities from the curriculum on their SDL. A mixed-method research design was employed.
                 Methods: Quantitative data were collected by using a self-administered questionnaire of 80 items measuring
                 students’ perceptions on their SDL capability as well as to explore students’ views about the influence of
                 components of the curriculum on their SDL. Additional two focus group discussions, each containing eight
                 participants from year-1 and year−2 students, were conducted. The quantitative data were analyzed using SPSS.
                 The focus group discussions were reviewed, coded, and then thematically analyzed.
                 Results: Our study showed a significant increase in SDL score on comparing students at year-1 with students at
                 year-2 (p = 0.002). Both year-1 and 2 students rated PBL tutorial discussion and tutors had high influence on their
                 individual learning; whereas, other curricular components such as lectures and testes had low influence on their
                 SDL ability. PBL tutorial discussion and module objectives showed strong correlation with students’ SDL scores,
                 r = 0.718 & r = 0.648 (p < 0.01), respectively. Besides, PBL tutorial discussion was found strongly correlated with
                 tutors (r = 0.599 (p < 0.01)) and module objectives (r = 0.574 (p < 0.01)). Assessment was highly correlated with
                 lectures (r = 0.595 (p < 0.01)). Findings from qualitative data showed that certain curricular components played role
                 in promoting students’ SDL. Tutorials analyzing problems played a major role on students’ self-directed learning
                 abilities.
                 Conclusions: Although the study implied that components of the hybrid curriculum, mainly PBL, could encourage
                 preclinical students’ self-directed learning, the curriculum is still not free from teacher-centred culture as the
                 majority of teachers still have high power in deciding the learning process. A further longitudinal study is needed
                 to verify the actual level and ability of medical students’ SDL.
                 Keywords: Self-directed learning, Preclinical students, Hybrid curriculum, Ethiopia
               * Correspondence: haftomki@yahoo.com
               1
                Department of biomedical science, Aksum University, Aksum, Ethiopia
               Full list of author information is available at the end of the article
                                                ©The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
                                                International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
                                                reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
                                                the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
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                   Kidane et al. BMC Medical Education            (2020) 20:7                                                                                       Page 2 of 10
                   Background                                                                        colleagues [28] indicated a significant effect of age on
                   Equipping medical professionals with skills essential for                         SDL ability: higher age medical students were more self-
                   lifelong learning is immensely required [1]. In today’s                           directed learners compared with students from the same
                   society, as scientific knowledge constantly develops,                             cohort of younger age. On the contrary, other studies
                   medical professionals should be able to learn and                                 have revealed no correlation between student age and
                   upgrade their competency from time to time [2]. Self-                             SDL skill [25, 27]. The relation between academic per-
                   directed learners have an adequate amount of account-                             formance and SDL is still not clear; some studies re-
                   ability to select the content to be studied, to assign time                       ported strong correlation [22, 24, 26] while others
                   for it, and to understand the content deeply using any                            reported weak relation [21].
                   method both inside and outside class [3]. Students                                   The feasibility of SDL in all cultural learning environ-
                   mostly need training and support to become a self-                                ments has also been an area of discussion. Culture influ-
                   directed learner [4, 5]. This support is necessary when                           ences students’ self-direction in learning [23, 29–33].
                   students are teacher dependent and not ready at the be-                           Thus, studying the effect of a hybrid curriculum on adult
                   ginning for self-directed learning (SDL) until they pass                          learners’ SDL in the African setting is necessary.
                   through a series of progressive stages [4].                                          So far, there are no studies conducted which investi-
                      To help learners persistently improve SDL skills, im-                          gate the effectiveness or level of self-directed learning in
                   plementation of appropriate teaching strategies and                               Ethiopian students in a hybrid curriculum like the New
                   activities has paramount importance [4]. Several studies                          Innovative Medical Curriculum (NIMC) schools. The
                   have indicated different teaching strategies and activities                       purpose of this study is, therefore, to explore how adult
                   that motivate students toward self-directed learning                              preclinical students’ in Ethiopian culture experienced
                   [6–8]. Problem-based learning (PBL) is one of such                                SDL and to see if they experienced the influence of the
                   widely accepted educational strategies that stimulate                             various elements of the hybrid curriculum on their SDL
                   SDL [8]. Evidence exists that PBL promotes SDL be-                                skill. We assumed that culture would influence SDL and
                   cause learners are responsible to plan, monitor, and                              year-two students to have higher levels of SDL ability
                   evaluate their learning process [9–11]. Within a PBL                              than year-one students. Because year-one students are
                   strategy, students usually work together in tutorials                             not ready for complete self-direction compared to stu-
                   analyzing real-world problems [12]. These tutorial au-                            dents in year-two who are relatively with high experi-
                   thentic problems promote students’ independent re-                                ences in PBL and supposed to pass through a series of
                   sponsibility for learning and help connect them with                              progressive stages. Besides, we supposed that the effect
                   the large world beyond the classroom [12, 13].                                    of age and academic performance between students in
                      To become a self-directed learner, there are promoting                         year-one and year-two would be comparable. This study
                   and deterring conditions related to the type of offered                           aims to provide information on the current lack of evi-
                   curriculum, and students’ and teachers’ level of under-                           dence on how students in Ethiopian medical schools
                   standing about SDL [14, 15]. Unlike innovative curricula,                         with hybrid curriculum experience SDL. In addition, it
                   a conventional curriculum is not likely to produce self-                          contributes information for evidence-based decision of
                   directed learners [16]. A large body of research indicated                        policymakers; it provides lesson for existing medical
                   graduates of PBL curricula are better self-directed                               schools elsewhere to consider SDL; and it is a great in-
                   learners [17, 18]. On the other hand, there are inconsist-                        put for future studies.
                   ent reports in different settings about the effect of a hy-                          In the current study, several questions related to SDL
                   brid PBL curriculum on students’ SDL ability [19]. By                             are addressed: What do preclinical students who already
                   hybrid curriculum is meant a curriculum that combines                             have a bachelor degree understand by the term SDL?
                   traditional teaching methods and PBL aiming to benefit                            How do preclinical students from year-one reflect their
                   from advantages of the innovative learning strategy [8,                           level of SDL skill and does this differ from students in
                   20]. Besides curriculum approach, there is no common                              year-two? How do preclinical students from year-one
                   consensus between the correlation of sociodemographic                             perceive the support from the various elements of the
                   factors such as curriculum year, age, and academic                                hybrid curriculum on their SDL skills? Is this different
                   achievement and students’ SDL [21–28]. Leatemia et al.                            from students in year-two?
                   [25] revealed higher level of SDL readiness in first-year
                   students compared to second-year medical students of a                            Methods
                   hybrid PBL curriculum. Novertheless, Frambach et al.                              Setting
                   [23] noted that students from three medical schools                               The study was conducted at Aksum University medical
                   (two had PBL-curriculum and one had hybrid PBL cur-                               school, Ethiopia. The medical school is among the 13
                   riculum) in different cultures progressively accustomed                           new medical schools in the country which adopted
                   the principle of SDL from year to year. Premkumar and                             NIMC with the support of the Ethiopian Federal
                   Kidane et al. BMC Medical Education            (2020) 20:7                                                                                       Page 3 of 10
                   Ministries of Health and Education to tackle the signifi-                         are arranged in five domains: self-awareness, learning
                   cant shortage of doctors and burden of diseases in the                            strategies,      learning       activities,     self-evaluation,        and
                   country [34]. The medical curriculum is a five-year                               interpersonal skills. The scale was found reliable with
                   programme and designed for candidates aged below 35                               Cronbach’s alpha coefficient for each domain varied
                   years who already have a BSc degree in biomedical                                 between 0.71 and 0.79 [37]. Besides, the questionnaire
                   sciences. The first 2 years of the curriculum are preclin-                        designed by Dolmans & Schmidt [14] was used to
                   ical years and the remaining 3 years are clerkship years                          explore students’ views about the influence of compo-
                   [34]. It is a hybrid curriculum, some elements, such as                           nents of the hybrid curriculum on their SDL. The items
                   weekly tutorial sessions are according to the PBL strat-                          are 20 in number and set in six themes: discussion in the
                   egies, still, other elements, high number of lectures, stick                      tutorial group, content tested, course objectives, lectures,
                   more to traditional teacher-centred approach [34]. Case                           tutor, and references. The coefficient alpha for each
                   analyses in PBL tutorials are embedded in the first                               theme was found between 0.51 and 0.82 [14]. All items
                   2 years of the preclinical programme and students have                            were rated by students whether they behave always (5),
                   to analyse multilevel PBL cases in a seven-step approach                          often (4), sometimes (3), seldom (2), or never at all (1).
                   through tutorial one (pre-discussion), self-study, and tu-                        A pilot study was conducted on four third-year medical
                   torial two (reporting session) [12]. Multilevel PBL paper                         students.
                   patient cases, which are constructed to address the core                             Two focus group discussions (FGDs), one containing
                   objectives of the preclinical years, are used to stimulate                        eight participants from year-one and one containing
                   basic science learning. In the pre-discussion session (2 h                        year-two students were conducted using similar inter-
                   long) students follow the first five steps of the seven-step                      view questions after the questionnaire survey was per-
                   approach and end-up with designing learning goals. Be-                            formed. The purpose of the FGDs was to get more
                   tween tutorials is time allotted for students’ self-study to                      insight and in-depth information about students’ under-
                   achieve all learning issues and get prepared for tutorial-                        standing of SDL and the influence of curricular compo-
                   two discussion.                                                                   nents on their SDL. The focus group was designed
                                                                                                     following the guidelines for Stalmeijer & colleagues [38]
                   Participants                                                                      and its duration was ranged from 1:30–2:00h long. Both
                   The study population was all year-one and year-two stu-                           FGD discussions were conducted in local language
                   dents of the medical school in Aksum. Almost all first-                           (Amharic) by two interviewers.
                   year (n=30 from 31) and second-year (n=32 from 38)
                   medical students of Aksum University participated in
                   the study. In both years students follow comparable                               Analysis
                   learning activities, a combination of PBL based learning                          Quantitative data were analyzed using IBM SPSS version
                   activities, like each one tutorial with problem analyses                          20 (IBM, Armonk, New York, USA). Mean and standard
                   and traditional based learning activities, like a weekly                          deviation of students’ SDL scores were computed. Inde-
                   high number of teacher-centred lectures. In both year-1                           pendent t-tests/ANOVA were used to investigate
                   and year-2, there are no training of other activities expli-                      whether means of the scores differed between years,
                   citly focusing on SDL. Data were collected after students                         ages, marital status, and academic performance (cumula-
                   completed all their course work, at the end of year-1                             tive grade point average, CGPA, of the particular year)
                   and year-2.                                                                       of students. Students’ level of self-directedness in learn-
                                                                                                     ing was ranked as low SDL (if they score within 60–140
                   Design                                                                            range), medium SDL (141–220 score), or high SDL
                   Wedid a cross-sectional study [35] on first- and second-                          (221–300 score) [37]. We analyzed all results using α=
                   year medical students at the School of Medicine. A                                0.05. Moreover, we used Pearson correlation to evaluate
                   mixed-methods research design [36] was employed to                                whether and how strongly curricular components and
                   explore students’ experience about their SDL skill and                            SDL skills were related.
                   support of various elements of the curriculum on their                               The focus group discussions were audiotaped and
                   SDL skill from March 26 – May 03/2019.                                            transcribed. The discussion contents were translated
                                                                                                     toEnglishlanguagebyoneofthefocusgroupinter-
                   Data collection                                                                   viewers and checked by another staff with good
                   The validated Likert-based self-rate scale for SDL                                English language skill. Subsequently, it was reviewed,
                   (SRSSDL) questionnaire developed by Williamson [37]                               coded, and then thematically analyzed by the main
                   was used to measure students’ perceptions of their SDL                            author and the two interviewers of the focus groups.
                   level. The questionnaire consists of 60 items related to                          There were repeated discussions among coders until
                   students’ level of self-directedness in learning and they                         agreement was reached.
                   Kidane et al. BMC Medical Education            (2020) 20:7                                                                                       Page 4 of 10
                   Ethical approval                                                                  with students at year-2 (p=0.002) was found in this
                   Ethical approval was obtained from the Institutional                              study.
                   Review Board (IRB) of Aksum University College of                                    In both year-1 and year-2, there were no significant
                   Health Sciences. Also, study participants were asked to                           effects of age, marital status, and academic performance
                   participate in the study voluntarily and written informed                         on students’ SDL scores (Table 2).
                   consent was obtained by all study participants.
                                                                                                     Influence of curricular components on students’ SDL skills
                   Results                                                                           The perceived influence of tutorial discussion, content
                   Quantitative results                                                              tested, module/case objectives, lectures, tutors, and de-
                   Overview of the personal aspects of participants                                  pendence on suggested references/sources on the indi-
                   The response rate was 97% (30/31; 26 male, 4 female)                              vidual study were scored by both year-1 and year-2
                   for year-one and 84% (32/38; 28 male, 4 female) for                               students. Both year-1 and 2 students rated PBL tutorial
                   year-two students. The study population in year-1 and                             discussion and tutors had a high influence on their inde-
                   year-2 were comparable (Table 1).                                                 pendent learning; whereas, other curricular components
                                                                                                     such as lectures and testes had a low influence on their
                   Students’ SDL ability                                                             SDL ability (Table 3).
                   The SDL readiness scale (SDLRS) questionnaire of year-                               Correlation between curricular components and stu-
                   1 and year-2 students was analyzed and compared. The                              dents’ self-rated SDL scores were also executed. Tutorial
                   overall     mean SDL readiness score for preclinical                              discussion and module/case objectives showed a strong
                   students at Aksum University medical school was 225.63                            correlation with SDL scores. Regarding the relationship
                   (±34.11). Year-1 students had a mean SDL score of                                 between curricular components, the tutorial discussion
                   212.3 (medium level) whereas year-2 students had a                                was correlated strongly with both tutors and module
                   mean score of 238.2 (high level) (Fig. 1). A significant in-                      objectives. Content tested was highly correlated with
                   crease in SDL score on comparing students at year-1                               lectures (Table 4).
                   Table 1 Characteristics of year-1 & year-2 respondents, Aksum                     Qualitative results
                   University, School of medicine, 2019                                              The focus group discussion from year-1 and the focus
                   Demographic factors                         Year-1                     Year-2     group discussion from year-2 provided in-depth infor-
                                                               N=30                       N=32       mation about students’ understanding of SDL and cur-
                   Age                                                                               ricular components that support or hinder SDL. The
                      20–24                                    2                          –          findings are presented below, clustered in three themes:
                                                                                                     students’ definition for SDL; support of the teacher of
                      25–29                                    28                         27         SDL; and curricular components and activities that influ-
                      30–34                                    –                          5          ence students’ SDL. Illustrative quotes are presented in
                   Marital status                                                                    italics.
                      Single                                   20                         19
                      Married                                  10                         13         Students’ definition for SDL
                   Recent background degree                                                          Students were asked to share their definitions of SDL
                                                                                                     and it could be understood that both cohorts have a cer-
                      BSc                                      30                         32         tain level of understanding about SDL. Compared to
                   Background education                                                              year-1, Year-2 students showed a deeper understanding
                      None health                              2                          2          of SDL. Year-2 students identified different aspects of
                      Medical Laboratory                       1                          1          SDL in their definitions. In their definition, the concept
                      Midwifery                                6                          4          SDL was described as the ability to identify learning
                      Nursing                                  5                          13         needs, to distinguish relevant references to meet the
                                                                                                     identified learning issues, to use appropriate learning
                      Optometry                                1                          1          strategies in achieving the identified learning gaps, and
                      Public Health officer                    15                         10         evaluating the effectiveness of the learning outcomes.
                      Psychiatry                               0                          1          The following quotation shows the general view on how
                   Academic performance (CGPA)                                                       year-1 students defined SDL:
                      >3.5                                     9                          11
                      3.0–3.5                                  18                         17            ‘….. I think now SDL means to me digging out and
                                                                                                        expanding the small direction we got in the class.’
                      <3.0                                     3                          4             [Year-1 student]